Post on 12-Feb-2017
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WOUNDSDr Joel Arudchelvamconsultant vascular and transplant surgeon
Wound /Ulcer / abrasion
A full thickness breach in the continuity of the skin
Partial thickness - Abrasion
Skin Anatomy
Wound healing
4 stages Haematoma formation Inflammation/ debridment Proliferation Remodelling / maturation
Stages of Wound Healing Inflammatory Stage Characterized by redness, heat, pain and swelling
approximately 4 to 5 days
Within 24 hours of the initial injury, neutrophils, monocytes and macrophages migrate to wound
control bacterial growth and remove dead tissue
Proliferative Phase
Granulation •Fibroblasts - collagen •new capillaries
Contraction •Wound edges pull together to reduce defect Epithelialization •Crosses moist surface
Remodeling
Reorganization of collagen (type III to type I)
increase in tensile strength
Tensile strength reaches only about 80% of pre-injury strength
Phases overlap
“Overlapping terms”
Wound healing
Primary intention
Secondary intention
Tertiary intention Delayed closure
Primary IntentionPrimary intentionHealing of a clean linear wound /surgical incision with sligth damage of tissues
Healing by second intention
extensive loss of tissue that is filled with granulation tissue and replaced by scar.
Classification of Wounds
1) Clean Wound: Operative incisional wounds t.
2) Clean/Contaminated Wound: When respiratory, gastrointestinal, genital,
and/or urinary tract have been entered. 3) Contaminated Wound:
open, traumatic wounds or surgical wounds involving a major break in sterile technique that show evidence of inflammation.
4) Infected Wound: old, traumatic wounds containing dead tissue
and wounds with evidence of a clinical infection (e.g., purulent drainage).
Complications of wound healing Deficient scar formation
wound dehiscence Excessive scar formation
Hypertrophic scar keloid
Exuberant granulation (proud flesh)
Non healing ulcer / chronic ulcers
Ulcers not showing signs of healing by 6 weeks are called chronic ulcers.
Causes for non-healing ulcers.
1. Local causes-Repeated trauma-Presence of foreign body / slough-ongoing infection / osteomyelitis
2. Regional causes
-Venous-Arterial-Neuropathic
3. Systemic causes -Diseases- diabetes mellitus, renal failure, etc.- Drugs- immunosuppressive drugs, cytotoxic-Nutritional deficiencies- hypo-albuminaemia, anaemia, vitamin and mineral
Differentiating Arterial, Venous and Neuropathic Ulcers
Differentiating Arterial, Venous and Neuropathic Ulcers
Treatment for chronic ulcers Local Regional Systemic
Treatment for chronic ulcersLocal Wound toilet
o Process of removal of slough, dead tissue, foreign bodies and draining pus.
o Following a wound toilet the wound base is made suitable for future granulation and epithelialisation.
Treatment for chronic ulcersRegional causes
Arterial- revascularization Venous - Strapping
(i.e. multilayer compression cotton wool
crape bandage
Cohesive - Coban
Adhesive - elasto-plaster.
Neuropathic- off loading
Treatment for chronic ulcers Systemic causes
Correct anaemia, vitamin deficiency and other nutritional deficiencies.
Optimization of underlying comorbidities.
Role of antibiotics in wound - indicated only in patients with evidence of local or systemic infection.
Wound dressings
The material which is applied to the surface of the wound to cover it is called a dressing. 1ry – dressing which touches the wound 2ry – dressing used to cover the primary
dressing
Ideal wound dressing
Dressings are applied to wounds for the following reasons; To provide a protective cover To maintain moisture To reduce pain To absorb exudates
In addition an ideal dressing have the following features; does not induce pain or itching easy to change Allows gaseous exchange Cheap Freely available
Types of Wound Dressings
Gauze dressings Tulle Hydrocolloid dressings Hydrogel dressings Alginate dressings Foam dressings Transparent film dressings Etc.
Gauze
Cheap Freely available
Dry Painful on removing Damages epithelium
Tulle
Cheap Freely available Easy removal
E.g : Vaseline
Hydrocolloid Dressings
Hydrocolloid Dressings
Made up of pectin based material Absorb exudate Occlusive – should not be used on
infected wounds Come in various shapes and sizes
Hydrogel Dressings
Hydrogel Dressings
Made up of primarily water in a polymer to maintain moist wound base
used in dry wounds Should not be used in exudating
wounds
Alginate Dressings
Alginate Dressings
Made up of seaweed
Absorb moderate amounts of drainage
becomes a gel when it comes into
contact with wound fluid through
Calcium/Sodium ion exchange
Foam Dressings
Foam Dressings
Made up of polyurethane foam Absorbs moderate to large amounts
of fluid Available in various sizes and shapes Some types my macerate peri wound
skin if it allows drainage laterally
Silver Dressings
Antimicrobial to reduce bio burden of wound through slow release of silver ion into the wound
e.g. Acticoat, Biatin Ag, Atruman Ag
Vacuum assisted closure VAC
Vacuum assisted closure VAC
Vacuum assisted closure VAC Macrostrain - visible stretch that occurs when negative
pressure contracts the foam.
Draws wound edges together Provides direct and complete wound bed contact Evenly distributes negative pressure Removes exudate and infectious materials
Microstrain - micro deformation at the cellular level
Reduces edema Promotes granulation tissue formation by facilitating cell
migration and proliferation
Vacuum assisted closure VAC Indications for use
Large wounds Cavities Large amount of exudate
Summary
Wound type Dressing
Dry Hydrocolloid, Hydrogel
Exudating wound Hydrocolloid, foam
Slough Hydrocolloid, hydrogels
Dead space / cavity Alginate, foam
When to change dressings
When there is an indication to change Soaking Pain Need to inspect
Discuss with doctor before changing
Avoid in chronic wounds
Iodine (Betadine) Hydrogen peroxide Other toxic agents
Avoid
• Do not tie gauze bandage tightly around limbs, digits – causes ischaemia
• Use – plaster , crepe instead
Thank You